Up-to-Date Breast, Cervical, and Colorectal Cancer Screening Test Use in the United States, 2021

Introduction We examined national estimates of breast, cervical, and colorectal cancer (CRC) screening test use and compared them with Healthy People 2030 national targets. Test use in 2021 was compared with prepandemic estimates. Methods In 2022, we used 2021 National Health Interview Survey (NHIS) data to estimate proportions of adults up to date with US Preventive Services Task Force recommendations for breast (women aged 50–74 y), cervical (women aged 21–65 y), and CRC screening (adults aged 50–75 y) across sociodemographic and health care access variables. We compared age-standardized estimates from the 2021 and 2019 NHIS. Results Percentages of adults up to date in 2021 were 75.7% (95% CI, 74.4%–76.9%), 75.2% (95% CI, 73.9%–76.4%), and 72.2% (95% CI, 71.2%–73.2%) for breast, cervical, and CRC screening, respectively. Estimates were below 50% among those without a wellness check in 3 years (all screening types), among those without a usual source of care or insurance (aged <65 y) (breast and CRC screening), and among those residing in the US for less than 10 years (CRC screening). Percentages of adults who were up to date with breast and cervical cancer screening and colonoscopy were similar in 2019 and 2021. Fecal occult blood/fecal immunochemical test (FOBT/FIT) use was modestly higher in 2021 (P < .001). Conclusions In 2021, approximately 1 in 4 adults of screening age were not up to date with breast, cervical, and CRC screening recommendations, and Healthy People 2030 national targets were not met. Disparities existed across several characteristics, particularly those related to health care access. Breast, cervical, and colonoscopy test use within recommended screening intervals approximated prepandemic levels. FOBT/FIT estimates were modestly higher in 2021.


Introduction
The US Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer (CRC) screening to reduce cancer mortality rates (1).Use of these services did not reach national targets for 2020 (2,3).We used 2021 National Health Interview Survey (NHIS) data to examine the most recent national estimates of screening test use, disparities, and comparisons to na-tional targets set by Healthy People (HP) 2030 (4).We compared estimates from 2021 with 2019 estimates to examine differences before and during the COVID-19 pandemic.

Methods
We used data from the 2021 and 2019 NHIS, an in-person survey of nationally representative samples of the civilian, noninstitutionalized US population (5).One sample adult was randomly selected from each household to self-report information about health and health services use (final sample adult response rates were 50.9% for 2021 and 59.1% for 2019) (5).Because of the COVID-19 pandemic, telephone interviews were attempted first in early 2021.In May 2021, in-person interviews resumed as local conditions allowed (5).Interviews conducted at least partially by telephone were higher in 2021 than in 2019 (62.8% vs 34.3%), and survey weighting methods were modified between these years (5).
We defined being up to date with screening as reporting having received a USPSTF-recommended test for any reason within recommended screening intervals (Table 1) (1).Each year since the survey redesign in 2019 (www.cdc.gov/nchs/nhis/2019_quest_redesign.htm),NHIS has included a set of cancer control questions sponsored by the Centers for Disease Control and Prevention and the National Cancer Institute.The content of these questions varies from year to year on a rotating basis.In 2019 and 2021, this content included additional questions about breast, cervical, and CRC screening tests to complement rotating core questions in those years about whether respondents ever received these tests and the time since the most recent test.These screening tests included mammography (breast cancer); Papanicolaou (Pap) and human papillomavirus (HPV) tests (cervical cancer); and colonoscopy, sigmoidoscopy, computed tomography (CT) colonography, home fecal occult blood test (FOBT) or fecal immunochemical (FIT) test, and FIT-DNA test (CRC).For blood stool tests, separate questions were not asked about FIT and guaiac tests.Rather, they were asked about in combination ("The following questions are about the blood stool or fecal occult blood test, fecal immunochemical or FIT test.These are tests to determine whether you have blood in your stool or bowel movement and can be done at home using a kit.You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.Have you ever had a blood stool or FIT test, using a HOME test kit?When was your most recent blood stool or FIT test, using a home test kit?").In 2019, questions about nonendoscopic CRC screening tests were asked of respondents who answered yes when asked if they had received a CRC test other than colonoscopy or sigmoidoscopy.In 2021, questions about nonendoscopic tests were asked of all respondents aged 40 years or older.NHIS responses regarding time since FIT-DNA test were not released in 2019 but were available for 2021.Because of this, CRC screening comparisons between years do not examine FIT-DNA use or overall CRC estimates (which include FIT-DNA).
Findings are national estimates of screening test use, reported as weighted percentages with 95% CIs.Survey design variables and survey weights were used in all analyses to account for the complex sample design and produce national estimates.We examined the percentage of US adults of screening age who were up to date with screenings for 2021 overall, and by sociodemographic and health care access characteristics, using Wald F-tests (significance set at P < .05).Overall estimates were also age-standardized to the projected 2000 US standard population (7).We compared agestandardized estimates of being up to date for 2021 and 2019.Estimates not meeting NCHS reliability standards were suppressed (8).We conducted analyses by using SAS version 9.4 (SAS Institute, Inc) and SUDAAN version 11.0.1 (RTI International).
Estimates were below 50% among those without a wellness check in 3 years across all screening types, among those without a usual source of care or insurance (aged <65 years) for breast and CRC screening, and among those residing in the US for less than 10 years for CRC screening.American Indian or Alaska Native (AI-AN) and Asian adults tended to have lower estimates by race across screening types.Hispanic adults were less likely than non-Hispanic adults to be up to date with cervical and CRC screening.Significant differences existed across all screening types by urbanization level, education, and income (Tables 2 and 3).

Discussion
Estimates suggest that approximately one-quarter of US adults of screening age were not up to date with breast, cervical, and CRC screening in 2021, and screening test use was below HP 2030 targets (4); CRC test use neared the target and exceeded the HP 2020 target (11).Colonoscopy was the most common CRC test, although 15% of adults were estimated to have received a stool blood test.Adults who were uninsured, without a usual source of care, or with shorter residence in the US had low screening uptake, consistent with previous evidence (2,12,13).By race, estimates for Asian and AIAN adults tended to be lowest across screening types.Hispanic adults were less likely to be up to date than non-Hispanic adults for cervical and CRC screening.Differences were also observed by education, income, and urbanization level.
The similarity in most up to date test estimates for 2021 and 2019 could reflect recommended screening intervals longer than 1 year, as well as recovery from reported declines in screening use during the COVID-19 pandemic (14)(15)(16)(17)(18)(19).Higher FOBT/FIT estimates for 2021 may suggest a shift toward increased home stool testing for CRC screening during the pandemic, consistent with other studies (20,21).Home-based testing has been identified as a screening facilitator during the pandemic (22).However, differences in survey methods and questions for nonendoscopic screening tests could have affected estimates.
Findings are subject to limitations.Data were self-reported, which could result in reporting bias (eg, recall bias).Limited evidence exists about self-reported HPV test accuracy (23,24).Assuming that all women aged 30 to 65 years with unknown HPV test use either did or did not have an HPV test did not yield large differences in cervical cancer screening estimates.Weights were adjusted for nonresponse, although nonresponse bias may be possible.Consistent with previous studies and HP targets (2-4,12,13,25), tests performed for any reason were included.Caution may be warranted in interpreting findings for small subgroups given missing information for some variables.
Approximately 1 in 4 adults of screening age were not up to date with breast, cervical, and CRC screening recommendations in 2021.Estimates were below current national targets and disparities persisted across sociodemographic and health care access groups, with particularly low use among those with less health care access.Use of these tests within recommended screening intervals may approximate prepandemic levels.FOBT/FIT use may have increased modestly.Survey changes could have affected estimates although findings are consistent with previous evidence (20,21).c Estimates suppressed because they did not meet NCHS standards for reliability (8).d P value reflects differences between Hispanic and non-Hispanic groups.
e Information about adults from other Hispanic origin or ethnicity groups is not available in the NHIS public-use file.
f Family income as a percentage of the federal poverty threshold, and multiply imputed by NCHS when missing (5,9).g Includes 4 groups based on the 2013 NCHS Urban-Rural Classification Scheme for Counties (5,10).
Howard M, Agarwal G, Lytwyn A. Accuracy of self-reports of Pap and mammography screening compared to medical record: a meta-analysis.Cancer Causes Control.2009;20(1):1-13.doi:10.1007/s10552-008-9228-423.Anderson J, Bourne D, Peterson K, Mackey K; Department of Veterans Affairs.Evidence brief: accuracy of self-report for cervical and breast cancer screening.VA Evidence-based Synthesis Program Reports 2019Feb.24.Shapiro JA, Klabunde CN, Thompson TD, Nadel MR, Seeff LC, White A. Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey.Cancer Epidemiol Biomarkers Prev.2012;21(6): 895-904.doi:10.1158/1055-9965.EPI-12opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

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continued on next page) PREVENTING CHRONIC DISEASE VOLUME 20, E94 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY OCTOBER 2023 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Table 1 .
Definitions of Being Up to Date With Breast, Cervical, and Colorectal Cancer Screening

Table 2 .
(5,9)ntage of Women Up to Date With Breast and Cervical Cancer Screening, United States, 2021 Overall percentages are presented unadjusted and age-standardized to the 2000 US standard population.Percentages were age-standardized using the follow-Information about adults from other Hispanic origin or ethnicity groups is not available in the NHIS public-use file.Family income as a percentage of the federal poverty threshold, and multiply imputed by NCHS when missing(5,9).
(5,10)iations: AIAN, American Indian or Alaska Native and includes AIAN only or in combination with another race; GED, general educational development; NA, not applicable; NCHS, National Center for Health Statistics; NHIS, National Health Interview Survey; USPSTF, US Preventive Services Task Force.aPvalue from Wald F tests, testing for any differences across groups excluding missing or unknown.bcPvalue reflects differences between Hispanic and non-Hispanic groups.deEstimatessuppressed because they did not meet NCHS reliability standards (8).f g Includes 4 groups based on the 2013 NCHS Urban-Rural Classification Scheme for Counties(5,10).hFor cervical screening, includes only age 65 years because USPSTF does not recommend routine screening beyond this age.The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Table 2 .
(5,10)tage of Women Up to Date With Breast and Cervical Cancer Screening, United States, 2021 American Indian or Alaska Native and includes AIAN only or in combination with another race; GED, general educational development; NA, not applicable; NCHS, National Center for Health Statistics; NHIS, National Health Interview Survey; USPSTF, US Preventive Services Task Force.aPvalue from Wald F tests, testing for any differences across groups excluding missing or unknown.bOverallpercentagesare presented unadjusted and age-standardized to the 2000 US standard population.Percentages were age-standardized using the follow-Information about adults from other Hispanic origin or ethnicity groups is not available in the NHIS public-use file.eEstimatessuppressed because they did not meet NCHS reliability standards (8).fFamily income as a percentage of the federal poverty threshold, and multiply imputed by NCHS when missing (5,9).gIncludes 4 groups based on the 2013 NCHS Urban-Rural Classification Scheme for Counties(5,10).hFor cervical screening, includes only age 65 years because USPSTF does not recommend routine screening beyond this age.The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
c P value reflects differences between Hispanic and non-Hispanic groups.d

Table 2 .
Percentage of Women Up to Date With Breast and Cervical Cancer Screening, United States, 2021 For cervical screening, includes only age 65 years because USPSTF does not recommend routine screening beyond this age.
(5,10)lue from Wald F tests, testing for any differences across groups excluding missing or unknown.bOverallpercentagesarepresentedunadjusted and age-standardized to the 2000 US standard population.Percentages were age-standardized using the following age groups: 50-64, 65-74 (breast); and21-34, 35-44, 45-65 (cervical).Percentages by sociodemographic and other variables are unadjusted.cPvaluereflects differences between Hispanic and non-Hispanic groups.dInformationaboutadults from other Hispanic origin or ethnicity groups is not available in the NHIS public-use file.eEstimatessuppressed because they did not meet NCHS reliability standards (8).fFamily income as a percentage of the federal poverty threshold, and multiply imputed by NCHS when missing (5,9).gIncludes 4 groups based on the 2013 NCHS Urban-Rural Classification Scheme for Counties(5,10).hTheopinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Table 3 .
Percentage of Adults Up to Date With Colorectal Cancer Screening, United States, 2021 Abbreviations: AIAN, American Indian/Alaska Native and includes AIAN only or in combination; GED, general educational development; NA, not applicable; NCHS, National Center for Health Statistics; NHIS, National Health Interview Survey; USPSTF, US Preventive Services Task Force.a P value from Wald F tests testing for any differences across groups excluding missing/unknown.b Overall percentages are presented as unadjusted and age-standardized to the 2000 US standard population.Percentages were age-standardized using the following age groups: 50-64, 65-75.Percentages by sociodemographic and other variables are unadjusted.